INSTRUMENTAL VAGINAL DELIVERY IN BAUCHI, NORTHEAST NIGERIA

Aliyu LD, Kadas AS, Hauwa MA*
Department of Obstetrics and Gynaecology Abubakar Tafawa Balewa University Teaching Hospital, Bauchi, Nigeria.
&
*Department of Obstetrics and Gynaecology Aminu Kano Teaching Hospital, Kano, Nigeria.
E- mail: zainalabidinaliyu@yahoo.com

*Correspondence: Aliyu LD.
Grant support: None
Subvention: Aucun
Conflict of Interest: None

Abstract

Background: Instrumental vaginal delivery is an important procedure which can be used as an alternative to caesarean section when indicated and thus reduce the caesarean section rate. There is a need to maintain and improve the skills for this procedure through training and research in order to improve the benefits for both mothers and their babies. Objective: To determine the incidence and indications of instrumental vaginal delivery and to compare the foetal and maternal outcome of vacuum and forceps deliveries.

Materials and Methods: This was a retrospective study on instrumental vaginal deliveries carried out between June 2009 and May 2011. The hospital records of all the patients who had had vacuum or forceps delivery were obtained and data on age, parity, booking status, and type of procedure performed, APGAR scores of babies delivered and complications were entered into a proforma and analyzed using SPSS software for Windows version 16.0.

Results: The rate of instrumental vaginal deliveries in this study was 0.69% of all deliveries. The rates were 0.54% and 0.15% for vacuum and forceps deliveries respectively. There was statistically significant difference in terms of APGAR scores =6 at 5 minutes and maternal complications between the two groups as the p-value was 0.000. There was no statistically significant difference with respect to booking status and parity of patients between the two groups as the p-values were 0.073 and 0.976.

Conclusion: The rate of instrumental vaginal deliveries in this institution is low and indications for the procedure are similar to those found elsewhere. There is statistically significant difference in terms of foetal and maternal outcomes between those who had forceps delivery and those who had vacuum delivery.

Key Words: Instrumental vaginal delivery, Vacuum and Forceps deliveries, Bauchi, Nigeria.

INTRODUCTION

Instrumental vaginal delivery is defined as vaginal delivery accomplished with the aid of instruments which can be vacuum or forceps1. It is carried out in the maternal interest, foetal interest or both. It is a procedure with a long history spanning more than two centuries and had undergone modifications and refinement to the present day.

The frequency of instrumental vaginal delivery varies from one country to another, and even in the same country, from one obstetric unit to another. The instrumental delivery (IVD) rate thus varies greatly between settings and the ideal rate is unknown2. In the Royal College of Obstetricians and Gynaecologist (RCOG) Consultants Conference, operative vaginal delivery rate of 10.5% was reported with a range of 4-20%. The consensus at the conference was to aim to lower the rate to an average of 8.5% (range 5-15%)3. In the developed countries it ranges between 10 and 15% in the UK and 4.5% in the United States2. In low resource countries IVD should provide a good alternative for delivery. However IVDs are underused in low resource settings2. Rates of IVD are low, ranging from 1% or less in Niamey (Niger), Ougadaougou (Burkina Faso) and Bamako (Mali) to 3% in Nouakchott (Mauritania).4 In contemporary practice however, there are conflicting reports on the trend in the general rate of instrumental vaginal delivery. Whereas in the US a decline has been reported5 a relatively constant rate is reported in some countries such as Scotland and Australia6. Data on IVD rates are scanty in Nigeria. Most studies were done on forceps delivery and its rate ranged from 0.9% to 6%7. IVD constitutes 3.6% of all deliveries at the Ahmadu Bello University Teaching Hospital in Zaria8. The current rate of forceps delivery in Ibadan is 1.57%9. Vacuum delivery rate of 1.5%, 1.6%, 1.7% were reported from Enugu, Ile-Ife and Ilorin respectively10,11,12.

The choice of which instrument to use varies from locality to locality and depends on the perception of practitioners on the relative safety of the instruments and their experiences. In some areas it depends on the availability of the instruments and the skill of the attending doctor. In other areas such as the USA, legal issues also determine the choice of instrument. In general, African obstetricians have shown more interest in the use of vacuum extraction over forceps.4 In the USA the vacuum is the instrument of choice13,14 whereas the forceps is the preferred instrument in Eastern Europe and South America15.

Studies have compared neonatal complications between vacuum and forceps, and they showed that neonatal complications were more with vacuum whereas maternal complications were more with forceps. A study from Pakistan showed no significant difference in the APGAR score at 5 minutes in forceps and vacuum deliveries16,17. This is supported by the Cochrane systematic review of nine randomized controlled studies that showed that vacuum extractor is no more likely to be associated with low APGAR score at 5 minutes when compared to forceps18. However, some other non-randomized controlled studies showed that maternal complications were more with forceps16,19.

According to the WHO and other UN agencies, assisted vaginal delivery is one of the six critical functions of basic emergency obstetric care20. This means that IVDs are such vital procedures and should be made available and accessible everywhere especially in developing countries where the need is high and caesarean section as alternative is not always available. Broadly speaking, the traditional indications for vacuum extraction are delayed labour, distress on the part of the baby or mother and medical conditions requiring shortening of the second stage of labour 10,16,21. The indications abound, the benefits such as reduction in caesarean section rate, reduction in the cost of delivery and brighter obstetric future are obvious hence the need for more studies in this area to provide practitioners with more information on this procedures to improve its utilization and safety.

In order to determine the incidence and indications of IVD at Abubakar Tafawa Balewa University Teaching Hospital, Bauchi, Nigeria and to compare the foetal and maternal outcomes of vacuum and forceps deliveries we studied the outcomes of the procedures over a two year period.

MATERIALS AND METHODS

This was a retrospective study carried out on all patients that had IVD between June 2009 and May 2011. Data were obtained from the hospital records which included the age, parity, booking status, and type of procedure performed, the APGAR scores of the babies and complications in the parturient. The data were analyzed for significance using SPSS software for Windows version 16.0.

RESULTS

During the period under review there were 19,412 deliveries and 134 patients had vacuum or forceps delivery, giving an incidence rate of 0.69%. The incidence of vacuum delivery was 0.54% while forceps delivery was 0.15%.

Table 1: Distribution of Age and Parity of Patients

Discussion

The overall rate of instrumental delivery (IVD) in this study was 0.69%. The rate of vacuum delivery was 0.54% while the rate of forceps delivery was 0.15%. The low rates were attributed to lack of experienced personnel to carry out the procedures. The overall rate is similar to what was reported from other developing countries in West Africa such as Niger, Burkina Faso, and Mali4. It is however lower than 3% reported from Nouakchott which may be due to a better health care delivery system compared to what we have in our environment4. It is also much lower than 3.6% reported from Zaria in Nigeria8. It is also very much lower than 8.5% recommended by RCOG3 and also lower than what is reported from developed countries2. The rate of forceps delivery in this study is lower than 1.57% reported from Ibadan Nigeria9 with better facilities and more experienced personnel. The vacuum delivery rate is also lower than what is reported elsewhere10,11,12.

Vacuum is more commonly used than forceps in this study which is in conformity with the reported trend in Africa.4 In the US the instrument of choice is the vaccum.13,14 The choice of the vaccum for IVD in Africa may be because of simplicity of use and the ease with which the skill to use it is acquired. These may be the same factors which made the vaccum the most commonly used instrument in our centre. In the US however legal issues also play a role in determining the choice of which instrument to use for IVD.

There was statistically significant difference between forceps and vacuum deliveries in terms of the number of babies delivered with asphyxia i.e APGAR score of 6 or less with p value of 0.000. This means babies delivered by vacuum have better APGAR scores compared to those delivered by forceps. A study elsewhere16,17 revealed no statistically significant difference and the finding was corroborated by a Cochrane systematic review of nine randomized controlled study18. This study also showed that there was a statistically significant difference in maternal complications between women delivered by forceps when compared to those delivered by vacuum (p=0.000); those delivered by vacuum sustained less complications. This is similar to what was reported elsewhere by other workers16,19.

It was found that there was no statistically significant difference between those delivered by forceps and those delivered by vacuum with respect to their booking status (p=0.073). This is contrary to our expectations, because those who were booked would have been more psychologically prepared and would have been screened for conditions that result in indications for IVD when compared to those who were not booked. Parity of women seemed not have determined which instrument was used in carrying out IVD in this study as there was no statistically significant difference between those who had forceps and those who had vacuum with respect to parity (P=0.0976). This was also contrary to our expectation, because women of lower parity are more prone to exhaustion, uterine inertia and other conditions that require performing an IVD compared to those with high parity who are more experienced and have more efficient uteri.

The indications for IVDs in this study were similar to those reported elsewhere10,16,21.

This study was retrospective and will therefore be limited by factors that are known to influence the strength of retrospective studies. The low rate of IVDs should be improved by training our residents in training on these procedures. Long term effects such neurological deficits and intelligent quotients of infants and long term complications in mothers will highlight the safety of these procedures as carried out at our centre and these inform the need for a prospective study on this topic.

In conclusion: The rate of instrumental vaginal deliveries in this institution is low and indications for the procedure are similar to those found elsewhere. There is statistically significant difference in foetal and maternal outcomes in those who had forceps delivery when compared with those who had vacuum delivery.

References

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